The development of a district-based model of intervention for improving the quality of maternal health care at primary level.

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Abstract

The Limpopo MCWH Directorate, concerned about the high perinatal and maternal mortality rates
arising from the poor quality of maternal health care provided at primary level, commissioned this
study to explore what would be the appropriate interventions that could be applied province-wide
to improve the quality of maternal health care at municipal and district level. Thus the study aimed to develop a useable and replicable model of intervention with Reproductive Health Management Teams (RHMTs) at municipal and district level that would lead
to improvements in the quality of maternal health care. The study objectives were to:
1. Identify indicators and the method for a baseline assessment of the quality of maternal health
care at municipal and district level. 2. Identify indicators that would permit an analysis of the factors that influence the key issues
emerging from the baseline assessment. 3. Develop a programme of intervention, with its monitoring and evaluation procedures, that
would address the factors that influence the key issues. 4. Recommend a strategy for replicating the intervention programme.
An action-research approach was adopted in this study, and was implemented in a series of
cyclical action-research steps in cooperation with the RHMTs. The study was implemented in 25
municipalities in Limpopo Province and was implemented over a period of 28 months, from
December 2001 to March 2004. Both qualitative and quantitative methodologies were used.
Indicators were identified to conduct a baseline assessment of the quality of maternal health care;
the tools were developed to collect the data necessary to calculate these indicators; the indicators
were applied to achieve a baseline assessment of the quality of care, and the information
analysed to identify priority key issues affecting the quality of maternal health care. These key
issues were identified as: the poor quality of the 1st ANC visit and poor management of labour.
These key issues were analysed in order to identify what were the most important influencing
factors affecting the quality of maternal health care. Staffing, supervision, referral systems,
support services and the planning and organisation of the health facilities were found to be the
most influential factors. Indicators were developed to measure these factors, with the data
collection tools required to collect the data necessary to calculate the indicators. The indicators
were measured to describe the current situation with regards to each.
Once the influencing factors had been identified, interventions were identified, prioritised and
planned for implementation in each municipal area. The priority interventions that could be
implemented at municipal level were: in-service training in antenatal care and the management of
labour; supervision of antenatal care and labour; audit of the service and improving referral
systems. Tools were developed to monitor the implementation of these interventions and the
outcomes of monitoring reported. The model to improve the quality of maternal health care developed in Limpopo Province is
possible to implement within the context of health services in South Africa. A limiting factor to full
implementation may well be staffing shortages, although this study did not set out to establish the
degree of influence that staffing shortages do actually exert. The real challenge to full
implementation, however, lies in the ability of managers at different levels to work together to
support quality service delivery, and for providers to deliver an integrated, comprehensive service
to pregnant women. Municipal and district level Reproductive Health Management Teams, with a
full mandate and good leadership, managerial, clinical and public health skills, have the potential
to address the most critical factors at the local level that are influencing the quality of care.